Limited coverage criteria – saxagliptin and saxagliptin-metformin

 

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Generic name	saxagliptin saxagliptin-metformin
Strength & form	2.5 mg, 5 mg saxagliptin tablet 2.5 mg/500 mg, 2.5 mg/850 mg, 2.5 mg/1000 mg saxagliptin-metformin tablet

Special Authority criteria	Approval period
As part of a combination treatment for type 2 diabetes mellitus: After inadequate glycemic control on maximum tolerated doses of dual therapy of metformin and a sulfonylurea OR dual therapy of metformin and an insulin	Indefinite

Practitioner exemptions

• None

Special notes

• Patients intolerant to a sulfonylurea may be considered for coverage
• Patients intolerant to glyburide may try another sulfonylurea (e.g., gliclazide, which is available through the Special Authority program)
• Patients who meet the limited coverage criteria for saxagliptin automatically receive coverage for linagliptin

Special Authority request form(s)

• Log in to eForms
• HLTH 5481 – Third-Line Anti-Diabetic Drugs (PDF, 672KB)